Changes in the epidemiology and management of bacterial infections in cirrhosis

Abstract

Patients with cirrhosis are susceptible to develop infections because of immune dysfunction, changes in microbiome and increase in bacterial translocation from the gut to systemic circulation. Bacterial infections can worse the clinical course of the disease, triggering the development of complications such as acute kidney injury, hepatic encephalopathy, organ failures and acute on chronic liver failure. In recent years, the spread of multi drug resistant bacteria made more challenging the management of infections in patients with cirrhosis. Hence, the mortality rate associated to sepsis is increasing in these patients. Therefore, the optimization of the management of infections has a high priority in cirrhosis. Herein we reviewed the recent changes in the epidemiology and the management of bacterial infections in patients with liver cirrhosis.

Keywords: Antimicrobial stewardship; Liver transplantation; Sepsis; Septic shock.

Figure 1.

Prevalence of multidrug-resistant (MDR) bacteria in patients with cirrhosis across the world. Different colors represent different rates of prevalence of MDR.

Figure 2.

Approach for the early diagnosis of infections in patients with cirrhosis. ^*Repeat work-up for infections in case of worsening of liver/renal function and/or development of further complications/organ failures. ^†Control renal and liver function at least every 48 hours.

Figure 3.

Algorithm for the management of patients with cirrhosis and bacterial infections. MDR, multi drug resistant; CA, community acquired. ^*Treatment as suggested for nosocomial infections (see Table 1). ^†See Table 1. ^‡Treatment should be prolonged for methicillin resistant Staphylococcus aureus bloodstream infections and other specific infections (e.g., endocarditis). Source control is mandatory (e.g., for abscesses). ^§Treatment of spontaneous bacterial peritonitis includes albumin expansion 1.5 g/kg on day 1 and 1 gr/kg on day 3.